QUALITY: Reducing Hospital Readmissions

Unplanned rehospitalizations are expensive for the Medicare program and bad for patients. They are also far too common in modern American medicine.

That was the message of a webinar, "Reducing Rehospitalizations: A National Priority," hosted by Commonwealth Fund. The webinar was spurred by a paper in the New England Journal of Medicine on rehospitalization among beneficiaries in fee-for-service Medicare. Rehospitalizations—when patients return to the hospital shortly after discharge—can reflect uncoordinated care and poor communication between providers and patients, in addition to taking a steep physical and psychological toll on patients.

The NEJM paper studied fee-for-service Medicare claims for 12 million beneficiaries from 2003-2004. It found that one in five were re-admitted to a hospital within 30 days of discharge. The authors estimated that about 10 percent of these readmissions were planned and therefore concluded that unplanned readmissions cost Medicare over $17 billion—out of $103 billion in total hospital payments made by Medicare that year.

Furthermore, rehospitalization rates varied tremendously between hospitals and between states—only 13 percent of patients were rehospitalized after 30 days in Idaho compared to 22 percent in Maryland. See chart below:

Paul M. Schyve, M.D, vice president of the Joint Commission, a quality accreditation organization, emphasized that patients need to be involved in tackling readmissions. Before patients leave the hospital, a "discharge planner," social worker, or nurse should plan follow-up care with patients and ensure that they understand their prescriptions and other care. Our colleague Joanne Kenen blogged recently on one such transitional care program at Penn in which advanced practice nurses  with expertise in gerontology do comprehensive hospital discharge planning for patients with multiple complex conditions.

In his presentation, Steve Jencks, M.D., a co-author of the paper, put the problem in the context of the larger medical system: "Rehospitalization may be the most powerful single example of the cost of fragmented, provider-centered care. I believe that a successful campaign to reduce rehospitalization will also make care more patient-centered."

Anne Mutti, a Senior Analyst for MedPAC, spoke to the lack of incentives in Medicare to reduce readmissions. Medicare provides no financial incentive for providers to work cooperatively to manage patients' care over time. Providers are paid by procedure (rather than in bundles for each episode of care). Furthermore, there is no penalty for poor quality, nor reward for good quality. MedPAC recommended reporting readmission rates to doctors and hospitals, and in the third year of collecting this data, making it publicly available. MedPAC also recommended eventually reducing payments to hospitals with relatively high readmissions rates for select conditions where we know standardized care can reduce readmissions.

The issue of hospital readmissions provide a proxy for the general problems in the American health care system. They reflect a fragmented system that leads to uncoordinated care and poor communication between providers and patients and wide variation across the country.

Solutions should address these problems head on by rewarding outcomes not output and creating the incentives and infrastructure for better coordinated care.